RE: COVERAGE OF HYPOGLOSSAL NERVE STIMULATORS

TO: MEDICAID MANAGED CARE PROVIDERS

Dear MetroPlus Health Provider,

Effective March 1, 2025, per New York State (NYS) Medicaid guidance, MetroPlus will begin coverage of Hypoglossal Nerve Stimulation (HGNS). HGNS is a treatment for individuals with Obstructive Sleep Apnea (OSA) who have difficulty tolerating positive airway pressure (PAP) therapy as a treatment or have failed PAP therapy.

HGNS coverage is limited for the following conditions:

• Individuals 13 -17 years old with Down Syndrome, and< a diagnosis of moderate to severe OSA with inability to tolerate PAP therapy or has failed PAP therapy.
• Individuals 18 years of age and over with a diagnosis of moderate to severe OSA and inability to tolerate PAP therapy or has failed PAP therapy.

State Billing Codes and Reimbursement Criteria

• Impacts Medicaid and HIV SNP:
  • For members between 13-17 years of age with a diagnosis of Down Syndrome.
    • CPT Codes: “64582”, “64583”, and “64584”
    • DiagnosisCodes:  “Q90.0”, “Q90.1”, “Q90.2”, and “Q90.9”
• Impacts Medicaid, HIV SNP, and HARP:
  • For members 13 years and older with a diagnosis of moderate to severe OSA with inability to tolerate PAP therapy OR has failed PAP therapy.
    • CPT Codes: “64582”, “64583”, and “64584”
    • Diagnosis Codes:  “G47.30 to37”, and “G47.39”

If you have any questions regarding this memo, please contact MetroPlusHealth at: [email protected].

Thank you.

MetroPlusHealth

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